Deficiency Records for Heron's Key
Updated as of April 01, 2023
This is not the most recent data for Heron's Key. For the most recent information, click here.
A list of the most recent deficiencies for Heron's Key. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2022-09-20 | 2022-10-29 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-09-20 | 2022-10-29 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2022-09-20 | 2022-10-29 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-09-20 | 2022-10-29 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-09-20 | 2022-10-29 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-09-20 | 2022-10-29 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-09-20 | 2022-10-29 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2022-09-20 | 2022-10-29 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-09-20 | 2022-10-29 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-09-20 | 2022-10-29 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-09-20 | 2022-10-29 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2022-09-20 | 2022-10-29 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-09-20 | 2022-10-29 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-09-20 | 2022-10-29 | N |
| Implement a program that monitors antibiotic use. | Health | 2022-09-20 | 2022-10-29 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-09-20 | 2022-10-29 | N |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2022-09-20 | 2022-10-29 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2022-09-16 | 2022-10-21 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2022-09-16 | 2022-10-21 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2022-09-16 | 2022-10-21 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-09-16 | 2022-10-21 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-09-16 | 2022-10-21 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-09-16 | 2022-10-21 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-09-16 | 2022-10-21 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-09-16 | 2022-10-21 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2022-09-16 | 2022-10-21 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2022-09-16 | 2022-10-21 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-01-04 | 2022-02-16 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-06-17 | 2021-07-15 | Y |
| Provide and implement an infection prevention and control program. | Health | 2020-12-04 | 2020-12-28 | Y |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2019-12-20 | 2020-01-24 | N |
| Respond appropriately to all alleged violations. | Health | 2019-12-20 | 2020-01-24 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-12-20 | 2020-01-24 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-12-20 | 2020-01-24 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2019-12-20 | 2020-01-24 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-12-20 | 2020-01-24 | N |
| Implement a program that monitors antibiotic use. | Health | 2019-12-20 | 2020-01-24 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-12-10 | 2020-01-03 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2019-12-10 | 2020-01-03 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2019-12-10 | 2020-01-03 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-12-10 | 2020-01-03 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-12-10 | 2020-01-03 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-12-10 | 2020-01-03 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-12-10 | 2020-01-03 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-12-10 | 2020-01-03 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2018-11-14 | 2019-02-01 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2018-11-14 | 2019-02-01 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2018-11-14 | 2019-02-01 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2018-11-14 | 2019-02-01 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2018-11-14 | 2019-02-01 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2018-11-14 | 2019-02-01 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2018-11-14 | 2019-02-01 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2018-11-14 | 2019-02-01 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2018-11-14 | 2019-02-01 | N |
| Develop a communication plan. | Fire Safety | 2018-11-14 | 2019-02-01 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2018-11-14 | 2019-02-01 | N |
| Provide emergency officials' contact information. | Fire Safety | 2018-11-14 | 2019-02-01 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2018-11-14 | 2019-02-01 | N |
| Establish methods for sharing information. | Fire Safety | 2018-11-14 | 2019-02-01 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2018-11-14 | 2019-02-01 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2018-11-14 | 2019-02-01 | N |
| Establish emergency prep training and testing. | Fire Safety | 2018-11-14 | 2019-02-01 | N |
| Establish staff and initial training requirements. | Fire Safety | 2018-11-14 | 2019-02-01 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2018-11-14 | 2019-02-01 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-11-14 | 2019-02-01 | N |
| Have properly sized and located compartments to protect residents from smoke. | Fire Safety | 2018-11-14 | 2019-02-01 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2018-11-20 | 2019-01-04 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2018-11-20 | 2019-01-04 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2018-11-20 | 2019-01-04 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2018-11-20 | 2019-01-04 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2018-11-20 | 2019-01-04 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-11-20 | 2019-01-04 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2018-11-20 | 2019-01-04 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2018-11-20 | 2019-01-04 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2018-11-20 | 2019-01-04 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2018-11-20 | 2019-01-04 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2018-11-20 | 2019-01-04 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-11-20 | 2019-01-04 | N |
